https://orcid.org/0000-0003-3997-1026
Figures
Abstract
Background
Depression may negatively affect stroke outcomes and the progress of recovery. However, there is a lack of updated comprehensive evidence to inform clinical practice and directions of future studies. In this review, we report the multidimensional impact of depression on stroke outcomes.
Methods
Data sources. PubMed, PsycINFO, EMBASE, and Global Index Medicus were searched from the date of inception.
Eligibility criteria. Prospective studies which investigated the impact of depression on stroke outcomes (cognition, returning to work, quality of life, functioning, and survival) were included.
Data extraction. Two authors extracted data independently and solved the difference with a third reviewer using an extraction tool developed prior. The extraction tool included sample size, measurement, duration of follow-up, stroke outcomes, statistical analysis, and predictors outcomes.
Risk of bias. We used Effective Public Health Practice Project (EPHPP) to assess the quality of the included studies.
Results
Eighty prospective studies were included in the review. These studies investigated the impact of depression on the ability to return to work (n = 4), quality of life (n = 12), cognitive impairment (n = 5), functioning (n = 43), and mortality (n = 24) where a study may report on more than one outcome. Though there were inconsistencies, the evidence reported that depression had negative consequences on returning to work, functioning, quality of life, and mortality rate. However, the impact on cognition was not conclusive. In the meta-analysis, depression was associated with premature mortality (HR: 1.61 (95% CI; 1.33, 1.96)), and worse functioning (OR: 1.64 (95% CI; 1.36, 1.99)).
Conclusion
Depression affects many aspects of stroke outcomes including survival The evidence is not conclusive on cognition and there was a lack of evidence in low-income settings. The results showed the need for early diagnosis and intervention of depression after stroke.
The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).
Citation: Shewangizaw S, Fekadu W, Gebregzihabhier Y, Mihretu A, Sackley C, Alem A (2023) Impact of depression on stroke outcomes among stroke survivors: Systematic review and meta-analysis. PLoS ONE 18(12): e0294668. https://doi.org/10.1371/journal.pone.0294668
Editor: Saraswati Dhungana, Tribhuvan University Institute of Medicine, NEPAL
Received: March 22, 2023; Accepted: November 6, 2023; Published: December 1, 2023
Copyright: © 2023 Shewangizaw et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This work was supported through the DELTAS Africa Initiative (DEL-15-01) by funds awarded to SS. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS) Alliance for Accelerating Excellence in Science in Africa and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (DEL-15-01) and the UK government. The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, WellcomeTrust or the UK government. There was no additional external funding received for this study. The funders mentioned had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Stroke is a neurological deficit attributed to an acute focal injury of the central nervous system by a vascular cause including cerebral infarction, intracerebral and subarachnoid hemorrhage [1]. They often face a range of problems including the inability to move some or whole parts of the body, problems with bladder and bowel control, numbness or strange sensations, trouble with judgment and memory, problems of understanding or forming speech, trouble in controlling or expressing emotions and, experiencing depressive symptoms [2].
Depression is one of the most common neuropsychiatric disorders that can happen before or in the early or late stages of a stroke. It affects approximately one-third of stroke survivors [3]. Post-stroke Depression (PSD) can occur as a continuation of pre-existing depression or may develop after the stroke. PSD is related to poor functional outcomes [5] and is associated with an increased mortality risk [4].
Kutlubaev and Hackett [5] conducted a systematic review of the predictors of depression after a stroke and the impact of depression on stroke outcomes. They reported a negative association between functional outcomes and PSD. Bartoli et al. [6, 7] and Cai et al. [8] also conducted a review and reported an increased mortality rate among survivors with depressive symptoms. Blöchl et al. [9] conducted a review on the impact of PSD on physical disability and reported poor functional outcomes among survivors with depressive symptoms.
Though these reviews included important studies and reported the impact of depressive symptoms on stroke outcomes they fail to review the other dimensions of stroke outcomes such as the ability to return to work. Our review included more studies and assessed more dimensions of stroke outcomes (the ability to return to work, cognition, and quality of life). Therefore, this systematic review and meta-analysis aimed to examine the relationship between depression and stroke outcomes (returning to work, functional recovery, cognition, quality of life, and mortality rate).
Methods
We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [10] guidelines to report the review. The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).
Search strategy
We searched four databases from the date of inception until 1st August 2023: PubMed, Embase, Global Index Medicus, and PsycINFO. Forward and backward search was conducted for the included studies. We have also searched University repositories and Google Scholar for grey literature. We used three big terms (terms for stroke, terms for depression, and terms for outcome) which were combined by the Boolean term AND (S1 File).
Eligibility criteria
We included longitudinal studies on depression conducted among adults diagnosed with various types of strokes. We included studies that reported both clinically diagnosed depression and studies that utilized screening tools. The outcomes we looked at were functioning, quality of life, returning to work, cognition, and mortality (rate and premature mortality)
Study selection process
The identified references were exported into EndNote reference manager software [11] and duplicates were removed. The references were reviewed using their title and abstracts. After that, the full body of the selected articles was checked for inclusion criteria. We then extracted the author, year of publication, sample size, measures used, and results of the articles. The article screening, selection, and extraction were done by two independent investigators (SS and WF). A third reviewer resolved discrepancies (YG).
Quality assessment
The quality of included studies was evaluated by the two investigators (SS and WF) independently using Effective Public Health Practice Project (EPHPP) [12]. EPHPP provides the means to assess study quality using its eight sections which include selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analysis. Results lead to an overall methodological rating as strong, moderate, or weak.
Data synthesis
We conducted a narrative synthesis to report the impact of depression on the ability to return to work, cognition, quality of life, functioning, and mortality rate. In the meta-analysis (homogeneous studies), we reported the pooled impact of PSD on functioning and mortality rate. For the mortality rate, we reported two pooled estimates as some studies reported hazard ratio (HR) while others reported odds ratio (OR). Since we expected heterogenicity we conducted a random effect meta-analysis. We used a funnel plot to see the risk of publication bias. We also conducted heterogeneity tests (I2) to examine the variation in the outcomes among the studies. We used Comprehensive Meta-analysis Software 4 for the meta-analysis [13].
Results
Study selection
Initially, we identified 25,646 articles. After removing 5,996 duplicates, 19,652 articles were screened using their title and abstract. Then, 150 full articles were reviewed, and we excluded studies which did not fulfil the inclusion criteria. Finally, eighty prospective studies that reported the relationship between depression and one or more stroke outcomes of interest (cognition, returning to work, quality of life, functional recovery, and mortality rate) were included (Fig 1).
Characteristics of the studies
Most of the studies (n = 66) were from high-income countries (HIC) (England, USA, Denmark, Norway, Korea, Australia, Canada, Poland, Finland, Singapore, Italy, Germany, Ireland, The Netherlands, Saudi Arabia, Japan, Scotland, and Singapore); and the rest (n = 14) were from middle-income countries (China, Nigeria, Brazil, Tunisia, Thailand, Lebanon, India and Serbia) and we did not come across studies from low-income countries which fulfilled the eligibility criteria.
Out of the eighty studies included in this review, four studies investigated the impact of depression on the ability to return to work, five on cognitive impairment, twelve on quality of life, forty-three on functional recovery and twenty-four on mortality. The number of participants in the reviewed studies ranged from 49–152, 243 at baseline assessment.
Risk of bias within the studies
The global rating of the articles based on the EPHPPs resulted in thirteen strong, fifty-six moderate, and eleven weak quality studies. The papers that were categorized as weak lacked an assessment of different factors that may affect the main outcome (S2 File).
Impact of depression on returning to work (n = 4)
Four studies [14–17] assessed factors predicting the ability to return to work after a stroke. These studies were from Australia [14], Brazil [15], the United States of America (USA) [16], and the Netherlands [17]. The mean age of the participants was 50 years. They considered time up to one month from the stroke incident as a baseline and followed them up to two years (Table 1).
Stroke survivors who had worked for at least a month before the stroke incident were eligible to participate. Different types of professions were included from full-time to part-time jobs with different occupations including self-employed and non-manual jobs.
Out of the four studies, one study reported that depression affected the ability to return to work [14] while the other three reported no significant association between returning to work and depression. This study reported higher odds of returning to work within six months among survivors without depressive symptoms (AOR = 4.92, 95% CI, (1.92–14.37)) [18]. None of the studies reported treatment for depression (Table 1).
Impact of depression on quality of life (n = 12)
Twelve studies [19–30] reported the impact of depression on stroke survivors’ quality of life; these studies were from the UK [19], Australia [30], Tunisia [20], Ireland [22], Nigeria [23], Brazil [24], Korea [21, 25], the Netherlands [26], China [27, 29], and Serbia [28]. The age range of the participants was 20–98 years; the sample size ranged from 49–1, 101 participants.
Ten studies found that depressive symptoms at various stages of recovery could affect the quality of life of a stroke survivor. The impact was true on both physical and mental components of quality of life.
In two studies that reported no association between depression and quality of life; one study reported that only 4% of the variance in the quality of life score was explained by depression while other predictors like economic status predicted 12% and activities of daily living predicted 19% of the variance [31] (Table 1).
Impact of depression on cognition (n = 5)
Studies conducted in England [19], Brazil [32], Finland [33], Lebanon [34] and South Korea [35] investigated the relationship between PSD and cognitive impairment. Baseline measures were taken one month after the stroke and followed up for 6 months in the South Korean study, and baseline measures were taken three months after the stroke and followed up for five years in the England study. Stroke survivors with severe cognitive impairment [19] or communication impairment due to dysphasia or dysarthria [19, 33, 35] and previous major depression with a history of suicide [32] were excluded from these studies.
Three of the studies reported no significant relationship between depression and cognitive impairment. Depression at 3 months was not associated with cognitive impairment at any point in time throughout the 5 follow-up years. Even though the mean Global deterioration scale (GDS) score was lower among the mild to moderate depression (MMD) group compared to the moderate to severe depression (MSD) group; there was no significant difference in the change of GDS scores over time. While Finland [33], and Lebanon study [34], reported a significant association between depression and the degree of cognitive deficit (Table 2).
Impact of depression on functional recovery (n = 43)
Different terminologies such as activities of daily living, dependency, functioning, and motor function were used. Forty-three studies [19, 22, 28, 29, 35–73] reported the impact of depression on functional recovery. All except two studies from Serbia [28] and China [29, 72] (upper middle-income countries) were from high-income countries. The number of participants ranged from 40–1753 (Table 2).
Thirty-two studies reported a significant association between depression and functional outcomes. Depression at baseline predicted functioning after 6–24 months (OR:2.7–3.7). The severity of depression was also associated with poor outcomes at 6 months and one year after the stroke. Stroke survivors with MSD had poorer outcomes compared to those who were MMD [29, 35, 69].
Stroke survivors with depressive symptoms had a lower score on a motor assessment scale. For every point increase on the depressive symptom scale, there was a decrease of 0.82 points and 0.77 points on different motor outcome scales indicating poorer outcomes [50]. The crucial part of stroke rehabilitation, trunk control at discharge was also influenced by the presence of depression at admission into the rehabilitation center (B = 9.057 (1.03,17.08) p = 0.027) [59] (Table 2).
On the other hand, 11 studies reported depression not related to functional outcomes even though one study reported PSD predicting inactive lifestyle rather than functional outcome or performance [39]. And in a study conducted in Norway found that depression was not an independent predictor for modified Rankin scores [68]. In a study conducted in India, no significant difference in the functional outcomes between stroke patients with depression and those without depression with inpatient rehabilitation programs was reported [73].
Regarding depression treatment, out of the total 43 studies, 15 studies [38, 40, 43, 47, 51–54, 56, 57, 60, 62, 67, 72, 73] reported the number of participants who were on treatment for depression whether it was anti-depressant or psychological therapy while one study excluded patients who were on treatment for depression [22]. In a few of these studies [38, 51, 67], functioning improvement was not associated with treatment for depressive symptoms (Table 2).
Impact of depression on mortality (n = 24)
Twenty-four studies [19, 69, 74–95] reported the impact of depression on the mortality rate. Of these, nine reported all-cause mortality while one study reported a suicide rate. The studies were from the USA [69, 77, 78, 83, 86, 89, 92–94], England [19, 82], Australia [74, 88], Denmark [84], Norway [90], Brazil [76], the Netherlands [79], Germany [85], Finland [87], Italy [91], Sweden and Finland [81], Lebanon [95], and South Korea [75, 80]. The sample size ranged from 84 to 152,243 participants and the age of the participants ranged from 18 to 74 years.
In the study that looked into suicide, suicide risk was higher in stroke survivors with depression compared to those without depression (AOR = 4, 95% CI (1.8–9.5)) [96]. Nineteen studies reported that depression was independently associated with an increased risk of all-cause mortality. Depression at 3 months following stroke was a predictor of mortality at 5 years of survival [19] and even over the period of 29 years [78]. Three studies reported depression was not associated with all-cause mortality (adjusted hazard ratio 1.15, 95% CI (0.76–1.75)) [69] and also no significant association between depression at baseline (one month after stroke) and long-term mortality [93].
While most of the studies did not report the treatment of depression, eight studies [80–83, 90, 91, 93, 94] reported the percentage of participants who were on antidepressant or psychological treatment. These studies showed that the probability of survival was significantly greater in the patients assigned to receive antidepressant treatment (χ2 = 4.7, df = 1, p = 0.03, log-rank test) [93] and also protective (HR 0.31;95% CI 0.11 to 0.86) [94] while compared with no depression treatment group. In another study, depression was a predictor of mortality at 12 months (OR 1.1, 95% CI (0.49,2.6)) when compared to patients with depression who were given problem-solving therapy [82]. One study excluded patients who were on anti-depressant [76] (Table 3).
Pooled impact of depression on functioning and mortality rate
Eleven studies reported the impact of depression on functioning. Stroke survivors with depression reported higher functioning problems than stroke survivors without depression (pooled OR = 1.94; 1.38, 2.73). The I-squared statistic is 85%, which tells us that 85% of the variance in observed effects reflects variance in true effects rather than sampling error (Fig 2).
Regarding the studies that report the association of depression with mortality rate, we produced two pooled estimates. The first estimate included sixteen studies that reported effect size with HR. The result showed that the mortality rate was higher among survivors with depression (pooled HR = 1.61; 1.33, 1.96) compared to survivors without depression. The I-squared statistic is 95.4%, which tells us that 95.4% of the variance in observed effects reflects variance in true effects rather than sampling error (Fig 3).
The second estimate included seven studies that reported effect size with OR. The result showed that the mortality rate was not significantly higher among survivors with depression (pooled OR = = 1.26; 0.88, 1.80) compared to survivors without depression (Fig 4).
Discussion
In this systematic review and meta-analysis, we have synthesized the impact of depression on stroke outcomes from the results of eighty prospective studies. Five main stroke outcomes were identified: cognitive impairment, quality of life, ability to return to work, functional recovery, and mortality. We presented a comprehensive narrative report on other outcome measures and reported the pooled impact of depression on functional recovery and mortality rate which were not fully addressed in previous reviews.
Three out of the four studies that investigated the impact of depression on the ability to return to work [15–17] reported that depression was not related to the stroke survivor’s ability to return to work. This finding may not be true as the survivors in these studies had mild to moderate stroke severity, and they were in the ‘younger’ age group. Other studies also refuted this conclusion [14, 16]. The inability to return to work is also associated with other factors such as cognitive status [17] and health insurance [14]. The inability to return to work may be different across different settings. These included the socioeconomic status and the available social welfare system which warrants the need for primary studies in low-resource settings to fully understand the impact and find ways to address these issues.
Our finding on the impact of depression on cognitive impairment is not to our expectation [19, 32, 35]. The no association result may be due to lower stroke severity and the exclusion of people with severe cognitive impairment from the studies. Previous studies reported cognitive impairment among both people with depression [97] and stroke [98]. We expect a multiplicative effect when a person had both depression and stroke. However, the results of these studies show the need for more studies to establish the relationship between depression and cognition among stroke survivors.
The association between depression and quality of life after stroke seems conclusive though two out of the twelve studies reported no association in a multivariable analysis. This might be because of the low rate of depression in those studies, and study participants had mild to moderate stroke severity. In these studies, stroke survivors who received treatment for depression were not included in the analysis [22, 29]. Patients who were treated in outpatient clinics and aphasic stroke survivors were also not included in the studies.
Regarding functional recovery, most of the studies indicated the impact of depression on this outcome while few studies reported low to no impact of depression on functional recovery. In these studies, participants who received immediate pharmacological treatment for depression showed better functional improvement by 30% compared to those who did not get treatment for depression [99]. This was also supported by our meta-analysis where depression was significantly associated with poorer functioning though the result needs to be interpreted with caution since the heterogeneity among studies is high.
Our pooled estimate of the impact of depression on mortality rate had significant implications for policy and practice, as shown in previous meta-analyses [6, 7, 9]. Depression increases both all causes, and suicide-related death compared to those without depression. Studies also suggested that early intervention with antidepressant treatments could be associated with the probability of longer survival [93, 94].
Though our review can be considered a comprehensive systematic review with a meta-analysis which synthesized a significantly higher number of prospective studies compared to previous reviews, it is not free from limitations. The first limitation was the definition of post-stroke depression. Stroke is mainly associated with chronic health conditions such as hypertension and diabetes. Depression is a common health problem among people with these chronic health conditions [100, 101]. These indicated the depression after stroke may be a continuation of pre-stroke depression. Nevertheless, the data shows that depression remains a significant issue that needs to be addressed for all stroke patients regardless of when it occurs. The second limitation was the heterogeneity of the studies. The heterogeneity was related to illness duration, the severity of the stroke, the setting and the measures used to assess depression. It’s important to consider all these factors while reading the finding.
The third limitation was related to the small sample size of the studies included in the meta-analysis which prevented us from sub-group analysis. The fourth limitation comes from the fact that most of the studies were conducted in high-income countries with better rehabilitation services.
Conclusion
Depression affects many aspects of stroke outcomes including survival. The evidence is not conclusive on some outcomes such as cognition. This review indicated the need for longitudinal studies with higher sample size especially in low-resource settings since the treatment for depression and stroke is not well-established and there is no well-established social welfare system. It also showed the need to provide mental health support for stroke survivors as it is related to better overall health and recovery.
Supporting information
S1 File. Search strategy for impact of depression on stroke outcomes.
https://doi.org/10.1371/journal.pone.0294668.s001
(DOCX)
S1 Table. Quality assessment for impact of depression on stroke outcomes.
https://doi.org/10.1371/journal.pone.0294668.s003
(DOCX)
References
- 1. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064–89. pmid:23652265.
- 2. Coupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of stroke. J R Soc Med. 2017;110(1):9–12. Epub 20170113. pmid:28084167; PubMed Central PMCID: PMC5298424.
- 3. Paolucci S. Epidemiology and treatment of post-stroke depression. Neuropsychiatric Disease and Treatment 2008:4(1) 145–154. 2008 pmid:18728805
- 4. Cai W, Mueller C, Li YJ, Shen WD, Stewart R. Post stroke depression and risk of stroke recurrence and mortality: A systematic review and meta-analysis. Ageing Res Rev. 2019;50:102–9. Epub 2019/02/04. pmid:30711712.
- 5. Kutlubaev MA, Hackett ML. Part II: predictors of depression after stroke and impact of depression on stroke outcome: an updated systematic review of observational studies. International journal of stroke: official journal of the International Stroke Society. 2014;9(8):1026–36. Epub 2014/08/27. pmid:25156411.
- 6. Bartoli F, Di Brita C, Crocamo C, Clerici M, Carra G. Early Post-stroke Depression and Mortality: Meta-Analysis and Meta-Regression. Frontiers in Psychiatry. 2018. pmid:30443225
- 7. Bartoli F, Lillia N, Lax A, Crocamo C, Mantero V, Carrà G, et al. Depression after Stroke and Risk of Mortality: A Systematic Review and Meta-Analysis. Stroke Research and Treatment. 2013;2013:862978. pmid:23533964
- 8. Cai W, Mueller C, Li Y-J, Shen W-D, Stewart R. Post stroke depression and risk of stroke recurrence and mortality: A systematic review and meta-analysis. Ageing Research Reviews. 2019;50:102–9. pmid:30711712
- 9. Blöchl M, Meissner S, Nestler S. Does depression after stroke negatively influence physical disability? A systematic review and meta-analysis of longitudinal studies. Journal of Affective Disorders. 2019;247:45–56. pmid:30654265
- 10. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Systematic reviews. 2021;10(1):89. pmid:33781348; PubMed Central PMCID: PMC8008539.
- 11.
The EndNote Team. EndNote. Philadelphia, PA: Clarivate Analytics; 2013.
- 12. Ciliska D, Miccouci S, Dobbins M. Effective public health practice project. quality assessment tool for quantitative studies. Hamilton, On: Effective Public Health Practice Project. 1998.
- 13. Melsen WG, Bootsma MCJ, Rovers MM, Bonten MJM. The effects of clinical and statistical heterogeneity on the predictive values of results from meta-analyses. Clinical Microbiology and Infection. 2014;20(2):123–9. pmid:24320992
- 14. Hackett ML, Glozier N, Jan S, Lindley R. Returning to paid employment after stroke: the Psychosocial Outcomes In StrokE (POISE) cohort study. PloS one. 2012;7(7):e41795. pmid:22848610
- 15. Nascimento LR, Scianni AA, Ada L, Fantauzzi MO, Hirochi TL, Teixeira-Salmela LF. Predictors of return to work after stroke: a prospective, observational cohort study with 6 months follow-up. Disability and Rehabilitation. 2021;43(4):525–9.
- 16. Schulz CH, Godwin KM, Hersch GI, Hyde LK, Irabor JJ, Ostwald SK. Return to work predictors of stroke survivors and their spousal caregivers. Work. 2017;57(1):111–24. pmid:28506018
- 17. van der Kemp J, Kruithof WJ, Nijboer TC, van Bennekom CA, van Heugten C, Visser-Meily JM. Return to work after mild-to-moderate stroke: work satisfaction and predictive factors. Neuropsychological rehabilitation. 2019;29(4):638–53. pmid:28441897
- 18. Nascimento LR, Scianni AA, Ada L, Fantauzzi MO, Hirochi TL, Teixeira-Salmela LF. Predictors of return to work after stroke: a prospective, observational cohort study with 6 months follow-up. Disability and rehabilitation. 2019:1–5. Epub 2019/06/27. pmid:31242399.
- 19. Ayerbe L, Ayis S, Crichton S, Wolfe CDA, Rudd AG. The long-term outcomes of depression up to 10 years after stroke; the South London Stroke Register. Journal of Neurology, Neurosurgery & Psychiatry. 2014;85(5):514–21. pmid:24163430
- 20. Boudokhane S, Migaou H, Kalai A, Jellad A, Borgi O, Bouden A, et al. Predictors of Quality of Life in Stroke Survivors: A 1-year Follow-Up Study of a Tunisian Sample. J Stroke Cerebrovasc Dis. 2021;30(4):105600. Epub 2021/01/18. pmid:33454587.
- 21. Choi-Kwon S, Choi JM, Kwon SU, Kang D-W, Kim JS. Factors that affect the quality of life at 3 years post-stroke. Journal of Clinical Neurology. 2006;2(1):34–41. pmid:20396483
- 22. Donnellan C, Hickey A, Hevey D, O’neill D. Effect of mood symptoms on recovery one year after stroke. International journal of geriatric psychiatry. 2010;25(12):1288–95. pmid:21086539
- 23. Gbiri CA, Akinpelu AO, Odole AC. Prevalence, pattern and impact of depression on quality of life of stroke survivors. International Journal of Psychiatry in Clinical Practice. 2010;14(3):198–203. pmid:24917320
- 24. Guajardo VD, Terroni L, Sobreiro MdFM, dos Santos Zerbini MI, Tinone G, Scaff Met al. The influence of depressive symptoms on quality of life after stroke: a prospective study. Journal of Stroke and Cerebrovascular Diseases. 2015;24(1):201–9. pmid:25440338
- 25. Kim ES, Kim JW, Kang HJ, Bae KY, Kim SW, Kim JT, et al. Longitudinal Impact of Depression on Quality of Life in Stroke Patients. Psychiatry Investig. 2018;15(2):141–6. Epub 2018/02/25. pmid:29475223; PubMed Central PMCID: PMC5900407.
- 26. Lam K-H, Blom E, Kwa VI. Predictors of quality of life 1 year after minor stroke or TIA: a prospective single-centre cohort study. BMJ open. 2019;9(11):e029697. pmid:31678939
- 27. Li L-J, Yao X-M, Guan B-Y, Chen Q, Zhang N, Wang C-X. Persistent depression is a predictor of quality of life in stroke survivors: results from a 5-year follow-up study of a Chinese cohort. Chinese medical journal. 2019;132(18):2206–12. pmid:31436596
- 28. Rabi Žikić T, Divjak I, Jovićević M, Semnic M, Slankamenac P, Žarkov M, et al. The effect of post stroke depression on functional outcome and quality of life. Acta Clinica Croatica. 2014;53(3.):294–301. pmid:25509239
- 29. Shi YZ, Xiang YT, Yang Y, Zhang N, Wang S, Ungvari GS, et al. Depression after minor stroke: The association with disability and quality of life–a 1‐year follow‐up study. International Journal of Geriatric Psychiatry. 2016;31(4):421–7. pmid:26343540
- 30. Orman Z, Thrift AG, Olaiya MT, Ung D, Cadilhac DA, Phan T, et al. Quality of life after stroke: a longitudinal analysis of a cluster randomized trial. Qual Life Res. 2022;31(8):2445–55. Epub 2022/01/25. pmid:35067819.
- 31. Smi C-K, Ji MC, Sun UK, Dong-Wha K, Jong SK. Factors that Affect the Quality of Life at 3 Years Post-Stroke. Journal of Clinical Neurology. 2006:34–41.
- 32. Baccaro A, Wang Y-P, Candido M, Conforto AB, Brunoni AR, Leite CdC, et al. Post-stroke depression and cognitive impairment: Study design and preliminary findings in a Brazilian prospective stroke cohort (EMMA study). Journal of Affective Disorders. 2019;245:72–81. pmid:30368073
- 33. Kauhanen M-L, Korpelainen JT, Hiltunen P, Brusin E, Mononen H, Määttä R, et al. Poststroke Depression Correlates With Cognitive Impairment and Neurological Deficits. Stroke. 1999;30(9):1875–80. pmid:10471439
- 34. Boutros CF, Khazaal W, Taliani M, Sadier NS, Salameh P, Hosseini H. Factors associated with cognitive impairment at 3, 6, and 12 months after the first stroke among Lebanese survivors. Brain Behav. 2023;13(1):e2837. Epub 2022/12/11. pmid:36495111; PubMed Central PMCID: PMC9847618.
- 35. Park GY, Im S, Lee SJ, Pae CU. The Association between Post-Stroke Depression and the Activities of Daily Living/Gait Balance in Patients with First-Onset Stroke Patients. Psychiatry Investig. 2016;13(6):659–64. Epub 2016/12/03. pmid:27909458; PubMed Central PMCID: PMC5128355.
- 36. Abdul-Sattar AB, Godab T. Predictors of functional outcome in Saudi Arabian patients with stroke after inpatient rehabilitation. NeuroRehabilitation. 2013;33(2):209–16. pmid:23949049
- 37. Ayerbe L, Ayis SA, Crichton S, Rudd AG, Wolfe CDA. Explanatory factors for the association between depression and long-term physical disability after stroke. Age and Ageing. 2015;44(6):1054–8. pmid:26447123
- 38. Cassidy EM, ’OConnor R, O’Keane V. Prevalence of post-stroke depression in an Irish sample and its relationship with disability and outcome following inpatient rehabilitation. Disability and Rehabilitation. 2004;26(2):71–7. pmid:14668142
- 39. Clark MS, Smith DS. The effects of depression and abnormal illness behaviour on outcome following rehabilitation from stroke. Clinical Rehabilitation. 1998;12(1):73–80. pmid:9549028
- 40. El Husseini N, Goldstein LB, Peterson ED, Zhao X, Olson DM, Williams JW Jr, et al. Depression status is associated with functional decline over 1-year following acute stroke. Journal of Stroke and Cerebrovascular Diseases. 2017;26(7):1393–9. pmid:28389192
- 41. Gillen R, Tennen H, McKee TE, Gernert-Dott P, Affleck G. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil. 2001;82(12):1645–9. pmid:11733876
- 42. Hama S, Yamashita H, Shigenobu M, Watanabe A, Hiramoto K, Kurisu K, et al. Depression or apathy and functional recovery after stroke. International Journal of Geriatric Psychiatry. 2007;22(10):1046–51. pmid:17702056
- 43. Herrman N, Black S, Lawrence J, Szekely C, Szalai J. The Sunnybrook stroke study. A prospective study of depressive symptoms and functional outcome. Stroke. 1998;29(3):618–24.
- 44. Johnston M, Pollard B, Morrison V, MacWalter R. Functional Limitations and Survival Following Stroke: Psychological and Clinical Predictors of 3-Year Outcome. International Journal of Behavioral Medicine. 2004;11:187–96. pmid:15657018
- 45. Kang H-J, Bae K-Y, Kim S-W, Lee E-H, Kim J-T, Park M-S, et al. Impact of acute phase depression on functional outcomes in stroke patients over 1 year. Psychiatry Research. 2018;267:228–31. pmid:29936374
- 46. Koivisto K, Viinämaki H, Riekkinen P. Poststroke depression and rehabilitation outcome. Nordic Journal of Psychiatry. 1993;47(4):245–9.
- 47. Kotila M, Numminen H, Waltimo O, Kaste M. Post‐stroke depression and functional recovery in a population‐based stroke register. The Finnstroke study. European Journal of Neurology. 1999;6(3):309–12. pmid:10210911
- 48. Kuptniratsaikul V, Kovindha A, Suethanapornkul S, Manimmanakorn N, Archongka Y. Complications During the Rehabilitation Period in Thai Patients with Stroke: A Multicenter Prospective Study. American Journal of Physical Medicine & Rehabilitation. 2009;88(2):92–9. pmid:19077674-200902000-00002.
- 49. Lai S-M, Duncan PW, Keighley J, Johnson D. Depressive symptoms and independence in BADL and IADL. Journal of rehabilitation research and development. 2002;39(5):589–96. pmid:17642023
- 50. Lin C, Babiker A, Srdanovic N, Kocherginsky M, Harvey RL. Depressive symptoms after stroke are associated with worse recovery. The International Journal of Psychiatry in Medicine. 2020;55(4):227–38. pmid:32050815
- 51. Loong CK, Kenneth NKC, Paulin ST. Post-Stroke Depression: Outcome following Rehabilitation. Australian & New Zealand Journal of Psychiatry. 1995;29(4):609–14. pmid:8825823.
- 52. Matsuzaki S, Hashimoto M, Yuki S, Koyama A, Hirata Y, Ikeda M. The relationship between post-stroke depression and physical recovery. Journal of Affective Disorders. 2015;176:56–60. pmid:25702600
- 53. Morris PLP, Raphael B, Robinson RG. Clinical depression is associated with impaired recovery from stroke. Medical Journal of Australia. 1992;157(4):239–42. pmid:1435438
- 54. Nannetti L, Paci M, Pasquini J, Lombardi B, Taiti PG. Motor and functional recovery in patients with post-stroke depression. Disability and Rehabilitation. 2005;27(4):170–5. pmid:15824047
- 55. Novack TA, Haban G, Graham K, Satterfield WT. Prediction of stroke rehabilitation outcome from psychologic screening. Arch Phys Med Rehabil. 1987;68(10):729–34. pmid:3662783.
- 56. Paolucci S, Antonucci G, Pratesi L, Traballesi M, Grasso MG, Lubich S. Poststroke depression and its role in rehabilitation of inpatients. Arch Phys Med Rehabil. 1999;80(9):985–90. pmid:10488996
- 57. Parikh RM, Robinson RG, Lipsey JR, Starkstein SE, Fedoroff JP, Price TR. The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up. Archives of neurology. 1990;47(7):785–9. pmid:2357159
- 58. Park G-Y, Im S, Oh CH, Lee S-J, Pae C-U. The association between the severity of poststroke depression and clinical outcomes after first-onset stroke in Korean patients. General hospital psychiatry. 2015;37(3):245–50. pmid:25817322
- 59. Pellicciari L, Sodero A, Campagnini S, Guolo E, Basagni B, Castagnoli C, et al. Factors influencing trunk control recovery after intensive rehabilitation in post-stroke patients: a multicentre prospective study. Topics in Stroke Rehabilitation. 2021:1–10.
- 60. Pohjasvaara T, Vataja R, Leppävuori A, Kaste M, Erkinjuntti T. Depression is an independent predictor of poor long‐term functional outcome post‐stroke. European Journal of Neurology. 2001;8(4):315–9. pmid:11422427
- 61. Saxena SK, Ng T-P, Koh G, Yong D, Fong NP. Is improvement in impaired cognition and depressive symptoms in post-stroke patients associated with recovery in activities of daily living? Acta Neurologica Scandinavica. 2007;115(5):339–46. pmid:17489945
- 62. Schmid AA, Kroenke K, Hendrie H, Bakas T, Sutherland J, Williams L. Poststroke depression and treatment effects on functional outcomes. Neurology. 2011;76(11):1000–5. pmid:21403112
- 63. Schubert DSP, Taylor C, Lee S, Mentari A, Tamaklo W. Physical consequences of depression in the stroke patient. General Hospital Psychiatry. 1992;14(1):69–76. pmid:1730403
- 64. Spruit-van Eijk M, Zuidema SU, Buijck BI, Koopmans RTCM, Geurts ACH. Determinants of rehabilitation outcome in geriatric patients admitted to skilled nursing facilities after stroke: a Dutch multi-centre cohort study. Age and Ageing. 2012;41(6):746–52. pmid:22885846
- 65. Stanislaw K. Difficulties in post-stroke gait improvement caused by post-stroke depression. Chinese medical journal. 2014;127(11):2085–90. pmid:24890157
- 66. Tse T, Linden T, Churilov L, Davis S, Donnan G, Carey LM. Longitudinal changes in activity participation in the first year post-stroke and association with depressive symptoms. Disability and Rehabilitation. 2019;41(21):2548–55. pmid:29889570
- 67. van de Weg FB, Kuik DJ, Lankhorst GJ. Post-stroke depression and functional outcome: a cohort study investigating the influence of depression on functional recovery from stroke. Clinical Rehabilitation. 1999;13(3):268–72. pmid:10392654
- 68. Wagle J, Farner L, Flekkøy K, Bruun Wyller T, Sandvik L, Fure B, et al. Early Post-Stroke Cognition in Stroke Rehabilitation Patients Predicts Functional Outcome at 13 Months. Dementia and Geriatric Cognitive Disorders. 2011;31(5):379–87. pmid:21720162
- 69. Willey JZ, Disla N, Moon YP, Paik MC, Sacco RL, Boden-Albala B, et al. Early depressed mood after stroke predicts long-term disability: the Northern Manhattan Stroke Study (NOMASS). Stroke. 2010;41(9):1896–900. pmid:20671256
- 70. Wilz G. Predictors of subjective impairment after stroke: Influence of depression, gender and severity of stroke. Brain Injury. 2007;21(1):39–45. pmid:17364518
- 71. Wulsin L, Alwell K, Moomaw CJ, Lindsell CJ, Kleindorfer DO, Woo D, et al. Comparison of two depression measures for predicting stroke outcomes. Journal of Psychosomatic Research. 2012;72(3):175–9. pmid:22325695
- 72. Yuan H, Zhang N, Wang C, Luo BY, Shi Y, Li J, et al. Factors of Hamilton Depression Rating Scale (17 items) at 2 weeks correlated with poor outcome at 1 year in patients with ischemic stroke. Neurological Sciences. 2014;35(2):171–7. pmid:23715751
- 73. Gupta A, Sharma S, Prakash N. Post Stroke Depression and Its Effect on Functional Outcomes during Inpatient Rehabilitation. International Journal of Stroke. 2022;17(3 Supplement):249.
- 74. Almeida OP, Xiao J. Mortality Associated with Incident Mental Health Disorders After Stroke. Australian & New Zealand Journal of Psychiatry. 2007;41(3):274–81. pmid:17464709
- 75. Choi JW, Lee SG, Kim TH, Han E. Poststroke suicide risk among older adults in South Korea: A retrospective longitudinal cohort study. International Journal of Geriatric Psychiatry. 2020;35(3):282–9. pmid:31859411
- 76. de Mello RF, Santos IdS Alencar AP, Benseñor IM, Lotufo PA, Goulart AC. Major Depression as a Predictor of Poor Long-Term Survival in a Brazilian Stroke Cohort (Study of Stroke Mortality and Morbidity in Adults) EMMA study. Journal of Stroke and Cerebrovascular Diseases. 2016;25(3):618–25. pmid:26725125
- 77. Ellis C, Zhao Y, Egede LE. Depression and increased risk of death in adults with stroke. Journal of Psychosomatic Research. 2010;68(6):545–51. pmid:20488271
- 78. Everson SA, Roberts RE, Goldberg DE, Kaplan GA. Depressive Symptoms and Increased Risk of Stroke Mortality Over a 29-Year Period. Archives of Internal Medicine. 1998;158(10):1133–8. pmid:9605786
- 79. Freak-Poli R, Ikram MA, Franco OH, Hofman A, Tiemeier H. Depressive symptoms prior to and after incident cardiovascular disease and long-term survival. A population-based study of older persons. Depression and Anxiety. 2018;35(1):18–31. pmid:29172249
- 80. Hong JP, Park S, Ahn S-H, Kim JS. Factors associated with post-stroke suicidal death. Journal of Psychiatric Research. 2018;96:135–7. pmid:29035724
- 81. Hornsten C, Lövheim H, Gustafson Y. The Association Between Stroke, Depression, and 5-Year Mortality Among Very Old People. Stroke. 2013;44(9):2587–9. pmid:23881955
- 82. House A, Knapp P, Bamford J, Vail A. Mortality at 12 and 24 Months After Stroke May Be Associated With Depressive Symptoms at 1 Month. Stroke. 2001;32(3):696–701. pmid:11239189
- 83. Jia H, Damush TM, Qin H, Ried LD, Wang X, Young LJ, et al. The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke. Stroke. 2006;37(11):2796–801. pmid:17008625
- 84. Jørgensen TSH, Wium-Andersen IK, Wium-Andersen MK, Jørgensen MB, Prescott E, Maartensson S, et al. Incidence of Depression After Stroke, and Associated Risk Factors and Mortality Outcomes, in a Large Cohort of Danish Patients. JAMA Psychiatry. 2016;73(10):1032–40. pmid:27603000
- 85. Kemper C, Koller D, Glaeske G, van den Bussche H. Mortality and nursing care dependency one year after first ischemic stroke: an analysis of German statutory health insurance data. Topics in stroke rehabilitation. 2011;18(2):172–8. pmid:21447467
- 86. Linda S, Williams M.D., Sushmita Shoma Ghose, Ph.D., and, Ralph W. Swindle, Ph.D. Depression and Other Mental Health Diagnoses Increase Mortality Risk After Ischemic Stroke. American Journal of Psychiatry. 2004;161(6):1090–5. pmid:15169698.
- 87. Melkas S, Vataja R, Oksala NKJ, Jokinen H, Pohjasvaara T, Oksala A, et al. Depression– Executive Dysfunction Syndrome Relates to Poor Poststroke Survival. The American Journal of Geriatric Psychiatry. 2010;18(11):1007–16. pmid:20808085
- 88. Morris PL, Robinson RG, Andrzejewski P, Samuels J, Price TR. Association of depression with 10-year poststroke mortality. American Journal of Psychiatry. 1993;150:124-. pmid:8417554
- 89. Morris PLP, Robinson RG, Samuels J. Depression, Introversion and Mortality following Stroke. Australian & New Zealand Journal of Psychiatry. 1993;27(3):443–9. pmid:8250788
- 90. Naess H, Lunde L, Brogger J, Waje-Andreassen U. Depression predicts unfavourable functional outcome and higher mortality in stroke patients: The Bergen Stroke Study. Acta Neurologica Scandinavica. 2010;122(s190):34–8. https://doi.org/10.1111/j.1600-0404.2010.01373.x.
- 91. Paolucci S, Gandolfo C, Provinciali L, Torta R, Toso V, on the behalf of the DSG. The Italian multicenter observational study on post–stroke depression (DESTRO). Journal of Neurology. 2006;253(5):556–62. pmid:16767539
- 92. Razmara A, Valle N, Markovic D, Sanossian N, Ovbiagele B, Dutta T, et al. Depression Is Associated with a Higher Risk of Death among Stroke Survivors. Journal of Stroke and Cerebrovascular Diseases. 2017;26(12):2870–9. pmid:28780250
- 93. Ricardo E, Jorge M.D., Robert G. Robinson M.D., Stephan Arndt Ph.D., and, Sergio Starkstein, M.D., Ph.D. Mortality and Poststroke Depression: A Placebo-Controlled Trial of Antidepressants. American Journal of Psychiatry. 2003;160(10):1823–9. pmid:14514497.
- 94. Ried LD, Jia H, Feng H, Cameon R, Wang X, Tueth M, et al. Selective Serotonin Reuptake Inhibitor Treatment and Depression are Associated with Poststroke Mortality. Annals of Pharmacotherapy. 2011;45(7–8):888–97. pmid:21750310.
- 95. Boutros CF, Khazaal W, Taliani M, Said Sadier N, Salameh P, Hosseini H. One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis. Front Neurol. 2022;13:973200. Epub 2022/12/02. pmid:36452174; PubMed Central PMCID: PMC9702576.
- 96. Choi JW, Lee SG, Kim TH, Han E. Poststroke suicide risk among older adults in South Korea: A retrospective longitudinal cohort study. International journal of geriatric psychiatry. 2020;35(3):282–9. Epub 2019/12/21. pmid:31859411.
- 97. Rock PL, Roiser JP, Riedel WJ, Blackwell A. Cognitive impairment in depression: a systematic review and meta-analysis. Psychological medicine. 2014;44(10):2029–40. pmid:24168753
- 98. Kalaria RN, Akinyemi R, Ihara M. Stroke injury, cognitive impairment and vascular dementia. Biochimica et Biophysica Acta (BBA)-Molecular Basis of Disease. 2016;1862(5):915–25. pmid:26806700
- 99. van de Weg FB, Kuik DJ, Lankhorst GJ. Post-stroke depression and functional outcome: a cohort study investigating the influence of depression on functional recovery from stroke. Clinical rehabilitation. 1999;13(3):268–72. Epub 1999/07/07. pmid:10392654.
- 100. Holt RI, De Groot M, Golden SH. Diabetes and depression. Current diabetes reports. 2014;14:1–9.
- 101. Li Z, Li Y, Chen L, Chen P, Hu Y. Prevalence of depression in patients with hypertension: a systematic review and meta-analysis. Medicine. 2015;94(31). pmid:26252317